K. M. Gould1,2,4, A. Zeymo1,2, K. S. Chan1,2,4, T. DeLeire2,4, N. Shara1,4, T. R. Shope3,4, W. B. Al-Refaie1,2,3,4 1MedStar Health Research Institute,Washington, DC, USA 2MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Integrated Surgical Services of MedStar Washington Region,Washington, DC, USA 4Georgetown University,Washington, DC, USA
Introduction: Obesity disproportionately affects vulnerable populations. Bariatric surgery is a long-term effective treatment for obesity and obesity-related complications; however, utilization rates of bariatric surgery are lower for racial minorities, low-income persons, and publicly-insured patients. The Affordable Care Act’s (ACA) Medicaid expansion increased access to health insurance for millions of low-income adults, but its impact on documented disparities in utilization of bariatric surgery by vulnerable populations has not been evaluated. We sought to determine the impact of the ACA’s Medicaid expansion on disparities in the utilization rates of bariatric surgery by insurance, income, and race.
Methods: 47,974 non-elderly adult patients (aged 18-64) who underwent bariatric surgery were identified in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion control states (Florida and North Carolina) from 2012-2015 using the Healthcare Cost and Utilization Project’s State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery overall and by insurance (Medicaid vs. privately-insured vs. uninsured), income (high- vs. low-income) and race (African Americans vs. whites). The differences in the counts of bariatric surgery by insurance, income and race were calculated to measure the gap in utilization rates of bariatric surgery.
Results: After the ACA’s Medicaid expansion, the adjusted incidence rate of Medicaid-insured and low-income bariatric surgical patients increased by 16.6% and 4.2% per quarter respectively in expansion states. No significant marginal changes were observed in the adjusted incidence rate of privately-insured and high-income bariatric surgical patients post-ACA in these expansion states. These changed rates of bariatric surgery resulted in a decreased measured gap in the difference of counts of bariatric surgery by insurance status and income in expansion states. In contrast, the overall trend in the utilization rate of bariatric surgery for African Americans vs. whites remained constant pre- and post-ACA’s expansion resulting in an unchanged gap in the difference of counts of bariatric surgery by race in expansion states. (Table)
Conclusion: The Medicaid expansion under ACA reduced the gap in bariatric surgery rates by income and insurance status, but racial disparities persisted. Future research should track these trends and focus on identifying other factors that can reduce disparity in bariatric surgery for minority patients.
